Pharmacovigilance
Adverse Reaction Report
  • Step 1 of 4
    Information about the patient,
    who experienced the adverse reaction
    This report applies to*
    Initials*
    Birth date or age*
    Gender*
    Country
    Height
    Weight
    * Mandatory field
    Next
  • Step 2 of 4
    Information about the product of ITALMED,
    from which the adverse reaction is suspected
    Name of the product (also strength/company, e.g. Amox, 1000mg)*
    Batch number
    Reason for use (e.g. pharyngitis, tonsillitis)
    Dose (e.g. 1g, twice per day)
    Type of administration (e.g. into the mouth)
    Start of administration (yyyy/mm/dd)
    Stop of administration (yyyy/mm/dd)
    Are you still taking/using the product?
    * Mandatory field
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    Next
  • Step 3 of 4
    Information about the
    adverse reactions occurred
    Date of initial occurrence of adverse reactions (yyyy/mm/dd)
    Description of reactions / symptoms (e.g. skin rash, itching, fever etc.)*
    Estimate the severity*
    Characterise "severe" further
    How is your/the condition, in relation to the adverse reaction, now?
    Did the reactions / symptoms resolve after withdrawal of the product?
    Did the reactions / symptoms repeat after re-administration of the same product?
    Was there a pregnancy while using the product?
    Additional information, e.g. administration of other medication at the same time, previous known drug reactions, known allergies or intolerances, other present diseases, available results from laboratory tests etc.
    * Mandatory field
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    Next
  • Step 4 of 4
    Contact details
    Name*
    Address
    Phone number or email address*
    By submitting the form you confirm to accept our privacy policy.
    * Mandatory field
    Back
    Submit Report
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